Senior Investigator (Aetna SIU)

event payment of fraudulent claims submitted to the Medicaid lines of business

• Researches and prepares cases for clinical and legal review

• Documents all appropriate case activity in case tracking system

• Facilitates feedback with providers related to clinical findings

• Initiates proactive data mining to identify aberrant billing patterns

• Makes referrals, both internal and external, in the required timeframe

• Facilitates the recovery of company and customer money lost as a result of fraud matters

• Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.

• Assists Investigators in identifying resources and best course of action on investigations

• Serves as back up to the Team Leader as necessary

• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.

• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings

• Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud

• Provides input regarding controls for monitoring fraud related issues within the business units

Required Qualifications

• WEST VIRGINIA RESIDENCY REQUIRED

• 3-5 years investigative experience in the area of healthcare fraud and abuse matters.

• Working knowledge of medical coding; CPT, HCPCS, ICD10

• Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables).

• Strong analytical and research skills.

• Proficient in researching information and identifying information resources.

• Strong verbal and written communication skills.

• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Preferred Qualifications

• Previous Medicaid/Medicare investigatory experience

• Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse.

• Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)

• Knowledge of Aetna's policies and procedures.

• Knowledge and understanding of complex clinical issues.

• Competent with legal theories.

• Strong communication and customer service skills.

• Ability to effectively interact with different groups of people at different levels in any situation.

Education:

• Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations).

Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$46,988.00 - $102,000.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 02/10/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.